"Alerted.org

JOB DESCRIPTION

Job Summary

The Medical Claim Review Nurse provides support for medical claim review activities. Responsible for ensuring timely claims payment processes, providing counsel to members regarding coverage and benefit interpretation, and appropriate level of care for provision of member services in alignment with state, federal, accrediting, and billing/coding guidelines and regulations. Contributes to overarching strategy to provide quality and cost-effective member care.

For this position we are seeking an RN with previous Inpatient Hospital, Skilled Nursing Facility experience, and outpatient coding experience including diagnosis. Candidates with knowledge of CPT/HCPCS codes, record review, chart audit, provider disputes, appeals, and 1500 & UB04 claim experience are highly preferred. Ability to apply state and federal regulations based on specific state and line of business. Must be able to work in a fast paced environment with frequent updates to reviews and processes. Further details to be discussed during the interview process.

Remote position

Work hours: Monday - Friday 8:00am - 5:00pm.

Essential Job Duties

• Performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing.

• Validates member medical records and claims submitted/correct coding to ensure appropriate reimbursement to providers.

• Identifies and reports quality of care issues.

• Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunity identified by the payment Integrity analytical team; makes decisions and recommendations pertinent to clinical experience.

• Facilitates document management, clinical reviews, bill audit findings and audit details in the database.

• Provides supporting documentation management for denial and modification of payment decisions.

• Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable federal and state regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care.

• Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions.

• Supplies criteria supporting all recommendations for denial or modification of payment decisions.

• Serves as a clinical resource for utilization management, chief medical officers, physicians and member/provider inquiries/appeals.

• Provides training and support to clinical peers.

• Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols.

• Collaborates and/or leads special projects.

Required Qualifications

• At least 2 years clinical nursing experience, preferably in a hospital setting, including at least 1 year of utilization review, medical claims review, claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience.

• Registered Nurse (RN). License must be active and unrestricted in state of practice.

• Experience working within applicable state, federal, and third-party regulations.

• Strong analytic and problem-solving abilities.

• Strong organizational and time-management skills.

• Ability to multi-task and meet deadlines.

• Attention to detail.

• Critical-thinking and active listening skills. • Common look proficiency.

• Decision-making and problem-solving skills.

• Strong verbal and written communication skills.

• Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs.

Preferred Qualifications

• Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ) or other health care certification.

• Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics.

• Billing and coding experience.

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Pay Range: $26.41 - $61.79 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.